Thomas W. Wainwright

A systematic review of patient reported outcomes and patient experience in enhanced recovery after orthopaedic surgery

INTRODUCTION Orthopaedic enhanced recovery after surgery (ERAS) providers are encouraged to estimate the actual benefit of ERAS according to the patients opinion by using patient generated data alongside traditional measures such as length of stay. The aim of this paper was to systemically review the literature on the use of patient generated information in orthopaedic ERAS across the whole perioperative pathway. METHODS Publications were identified using Embase(™), MEDLINE(®), AMED, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library and the British Nursing Index. Search terms related to experiences, acceptance, satisfaction or perception of ERAS and quality of life (QoL). FINDINGS Of the 596 abstracts found, 8 papers were identified that met the inclusion criteria. A total of 2,208 patients undergoing elective hip and knee arthroplasty were included. Patient satisfaction was reported in 6 papers. Scores were high in all patients and not adversely affected by length of stay. QoL was reported in 2 papers and showed that QoL scores continued to increase up to 12 months following ERAS. Qualitative methods were used in one study, which highlighted problems with support following discharge. There is a paucity of data reporting on patient experience in orthopaedic ERAS. However, ERAS does not compromise patient satisfaction or QoL after elective hip or knee surgery. The measurement of patient experience should be standardised with further research.

A review of virtual reality based training simulators for orthopaedic surgery.

This review presents current virtual reality based training simulators for hip, knee and other orthopaedic surgery, including elective and trauma surgical procedures. There have not been any reviews focussing on hip and knee orthopaedic simulators. A comparison of existing simulator features is provided to identify what is missing and what is required to improve upon current simulators. In total 11 hip replacements pre-operative planning tools were analysed, plus 9 hip trauma fracture training simulators. Additionally 9 knee arthroscopy simulators and 8 other orthopaedic simulators were included for comparison. The findings are that for orthopaedic surgery simulators in general, there is increasing use of patient-specific virtual models which reduce the learning curve. Modelling is also being used for patient-specific implant design and manufacture. Simulators are being increasingly validated for assessment as well as training. There are very few training simulators available for hip replacement, yet more advanced virtual reality is being used for other procedures such as hip trauma and drilling. Training simulators for hip replacement and orthopaedic surgery in general lag behind other surgical procedures for which virtual reality has become more common. Further developments are required to bring hip replacement training simulation up to date with other procedures. This suggests there is a gap in the market for a new high fidelity hip replacement and resurfacing training simulator.

Older patients have the most to gain from orthopaedic enhanced recovery programmes

BACKGROUND Between August 2007 and May 2009, 2128 consecutive patients underwent either primary hip or knee joint replacement surgery at our institute on an enhanced recovery pathway. We aimed to investigate the potential benefits of this pathway in patients over the age of 85 years. METHODS Data extracted from Hospital Episode Statistics were analysed. This data are prospectively collected and independently collated. RESULTS In all patients median length of stay was reduced when compared with both our own data before the introduction of the pathway (6 to 4 days) and national averages over the same time period for both hip and knee replacements (5 to 4 days). Difference in length of stay was most pronounced in the group of patients aged 85 years and over (9 to 5 days for total hip replacement and 8 to 5 days for total knee replacement). Nearly all patients were discharged directly home (97.4%). Readmission rates were over 45% lower in patients aged 85 and over when compared with national averages (5.2 vs. 9.4%). CONCLUSIONS This is the first series in the literature to assess the role of enhanced recovery pathways in the very elderly. This study not only shows that successful fast track rehabilitation can be achieved in the very elderly population undergoing elective joint replacement surgery, but that it is this cohort of vulnerable patients who have the most to gain from such multidisciplinary recovery programmes.

Enhanced recovery after surgery (ERAS) and its applicability for major spine surgery.

This article examines the relevance of applying the Enhanced Recovery after Surgery (ERAS) approach to patients undergoing major spinal surgery. The history of ERAS, details of the components of the approach and the underlying rationale are explained. Evidence on outcomes achieved by using the ERAS approach in other orthopaedic and complex surgical procedures is then outlined. Data on major spinal surgery rates and current practice are reviewed; the rationale for using ERAS in major spinal surgery is discussed, and potential challenges to its adoption are acknowledged. A thorough literature search is then undertaken to examine the use of ERAS pathways in major spinal surgery, and the results are presented. The article then reviews the evidence to support the application of individual ERAS components such as patient education, multimodal pain management, surgical approach, blood loss, nutrition and physiotherapy in major spinal surgery, and discusses the need for further robust research to be undertaken. The article concludes that given the rising costs of surgery and levels of patient dissatisfaction, an ERAS pathway that focuses on optimising clinical procedures by adopting evidence-based practice and improving logistics should enable major spinal surgery patients to recover more quickly with lower rates of morbidity and improved longer-term outcomes.

A Novel Technique for the Removal of Well-Fixed Cementless, Large-Diameter Metal-on-Metal Acetabular Components

Removing well-fixed cementless acetabular components can be a challenge for every orthopedic surgeon involved in revision hip arthroplasty. Forceful removal of such components often leads to acetabular bone loss and compromises reimplantation of a new socket. Instruments like the Explant Acetabular Cup Removal System (Zimmer, Warsaw, Ind) are developed to avoid such issues. We report a novel technique, cementing a polyethylene liner inside the uncemented metal-on-metal shell and using systems such as the Explant to safely extract it without the need for matching large-diameter heads. We successfully used this technique on 3 occasions and recommend its use.

What is the role of minimally invasive surgery in a fast track hip and knee replacement pathway

INTRODUCTION Minimally invasive hip and knee replacement surgery (MIS) continues to receive coverage in both the popular press and scientific literature. The cited benefits include a smaller scar, less soft tissue trauma, faster recovery, reduced hospital stay, decreased blood loss and reduced post-operative pain. These outcomes are highly desirable and consistent with the aims of fast track hip and knee pathways. This paper evaluates the literature and discusses whether performing MIS over conventional surgical techniques offers advantages in a fast track hip and knee pathway. METHODS An English language literature search was performed using the MEDLINE and PubMed databases. Case series, randomised controlled trials and systematic reviews were included in the review. RESULTS The reported improvements in recovery brought about by MIS must be considered multifactorial. In combination with improved clinical pathways, MIS can be associated with quicker recovery and shorter length of hospital stay. CONCLUSIONS There is insufficient evidence to indicate that surgical technique alone makes a significant difference to recovery or reduces soft tissue trauma. No consensus on whether to use MIS techniques in fast track hip and knee replacement pathways can therefore be drawn. This is especially important given that the complication rates of MIS in the low to medium volume surgeon appear unacceptably high compared with standard approaches. It is also too early to assess the long-term effects of MIS on implant survival.

More than just ticking a box…how patient and public involvement improved the research design and funding application for a project to evaluate a cycling intervention for hip osteoarthritis

AbstractPlain English summaryInvolving patients and the public in research helps to ensure that research remains relevant, and has an impact on the people it aims to benefit. Funding bodies now require patients and the public to be involved at all stages of research. Patients and members of the public were involved from the outset in research into a cycling and education programme for hip osteoarthritis. A group discussion took place with six participants from a trial of the programme. The group provided feedback on several areas including the relevance of the research, how the researchers proposed to recruit patients, the research design, the programme itself (including what they liked/didn’t like about it), and how the researchers could publicise the research findings. The feedback received was invaluable, and helped shape the entire research project and funding application. The cycling and education programme has been extended in line with comments received from the group. They also helped identify the best way of gathering information from research participants and had suggestions for sharing the results, both of which were incorporated into the funding application. Often involving patients and the public in research can be seen as a ‘tick box’ exercise. However, this example shows how crucial involving patients and the public in research design is. It also shows how the funding application was made stronger as a result of patient input. Researchers should be encouraged to work closely with patients and the public to ensure their research is of the highest quality.AbstractBackground Involving patients and the public in research is an essential activity to ensure relevant, accessible, and appropriate research. There is increasing obligation from funding bodies on researchers to have well thought through plans for involving the public, and indeed it is often a condition for funding. Patient and public involvement activity in this project was conducted to inform a funding application to investigate the effectiveness of a cycling and education intervention in the treatment of hip osteoarthritis. Methods Six participants from a feasibility programme of the intervention attended a two-hour patient and public involvement consultation group to provide feedback on various aspects of the proposed research and intervention. During the consultation group, two independent facilitators followed a detailed plan formulated with the research team. Feedback was validated by the attendees via email following the consultation, and a report was issued to the research team. Further feedback on subsequent changes was sought via email and telephone with members of a Patient Advisory Group. Results The patient and public involvement consultation group provided invaluable feedback and suggestions which impacted on the design and quality of the research project and the intervention. Key changes to the intervention included extending the duration of the cycling programme from six to eight weeks, and inclusion of an exercise diary to promote adherence to the intervention. Key feedback regarding the design of the research and funding application included suggestions for methods of dissemination, and confirmation of the primary outcome measure. Conclusions Patient and public involvement was crucial to the design of the proposed research and intervention. It informed many aspects of the research design and made the funding application stronger as a result. Involving patients and the public in research is much more than an obligation, or ‘tick box’ exercise. It can change and improve research quality, which is crucial when answering questions that are meaningful and important to patients, and which leads to increased impact. Collaboration with patients and the public should be planned and reported from the conception of a research idea where the impact of such input can be considerable.

Metal-on-Metal Resurfacing and the Cost to the Nation: A Conservative Estimate of the Unexpected Costs Required to Implement the New Metal-on-Metal Follow-Up Programme in the UK

Introduction: Metal-on-metal hip resurfacings (HR) have been widely used over the last 10 years due to their perceived advantages in younger active individuals. However, concerns over the use of metal-on-metal articulations, following the withdrawal of the ASR (DePuy Orthopaedics Inc., Warsaw, Indiana), have led the British Orthopaedic Association (BOA)/British Hip Society (BHS) to issue guidance on the long-term follow-up of these patients.

Local Anaesthetic Infiltration in Joint Replacement Surgery: What Is Its Role in Enhanced Recovery?

The last 10 years has seen the increased use of enhanced recovery pathways across several surgical specialities. A prerequisite of enhanced recovery is the ability to mobilise patients early. This is dependent upon good postoperative pain control. A number of different techniques have been employed in joint replacement surgery to address this issue. This paper focuses upon the current evidence for local infiltration anaesthesia.

Does virtual-reality training on orthopaedic simulators improve performance in the operating room?

This paper summarises recent validation studies and evidence demonstrating whether training on virtual reality (VR) simulators directly relates to improved performance in-vivo for orthopaedic surgical procedures. This research provides a summary of transfer validity on virtual reality orthopaedic simulators. This covers studies which have shown validation of simulators and have shown the transfer of simulator-acquired skill to the operating room. The findings of this study are that there are 6 studies showing transfer of skill for VR to in-vivo However more studies assessing efficacy and transfer validity are required to conclusively quantify the transfer validity of VR orthopaedic simulators. However there is a popular positive opinion for the ability of VR training to convert into better in-vivo performance.